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  • New Webpage Maps APTA's Coalition Connections

    "Better together"—the idea that more gets done when everyone's pulling in the same direction—has been a key theme within APTA for a few years now. But the association extends that idea far beyond its own members and components, and now you need look no further than a new APTA webpage for proof.

    Now available at APTA.org: a new resource that lists the coalitions, alliances, and other shared interest groups in which the association participates to help highlight important issues and bring the profession's voice to the table. The listings are grouped as "advocacy," "payment," and "practice," and include links to the coalitions themselves whenever possible.

    It's not a short list. As of the publication of the page, APTA lists no fewer than 30 groups in which it has involvement, including the Therapy Cap Coalition, the Coalition to Preserve Rehabilitation, the Disability and Research Rehabilitation Coalition, the Joint Commission, and the Academy of Nutrition and Dietetics, to name a few.

    The association's involvement in shared interest groups has played a significant role in some clear gains for patients and the physical therapy profession, including the Alliance for Integrity in Medicare Coalition's work in debunking of the "improvement standard" myth brought to light through the Jimmo v Sibelius settlement agreement, and the National Physical Activity Plan Alliance efforts to focus attention on the importance of physical activity as a way to improve public health.

    Want more information on APTA's involvement in other groups? Email advocacy@apta.org or practice@apta.org.

    APTA Fact Sheets on 2018 Outpatient Payment, Home Health Now Available

    Now available to APTA members: context and details to help you understand final 2018 rules from the Centers for Medicare and Medicaid Services (CMS) on the home health (HH PPS) and outpatient (OPPS) prospective payment systems.

    The final OPPS rule includes provisions that APTA supported—particularly moves toward reimbursement for outpatient-based total knee arthroplasty (TKA) and "non-enforcement" of direct supervision requirements for outpatient therapeutic services delivered in designated critical-access hospitals and rural hospitals with fewer than 100 beds. The rule also includes an overall 2% payment increase for outpatient hospitals and a 1.9% boost for ambulatory surgical centers. To access the fact sheet, visit the APTA Medicare Payment and Policies for Hospital Settings webpage. Scroll to the "Outpatient Care" area and look under "APTA Fact Sheets and Summaries."

    After receiving significant opposition from APTA, the APTA Home Health Section, and other professional and consumer advocacy organizations, CMS backed off on a proposed rule to adopt a payment system that, among other changes, would have removed therapy service-use thresholds from the payment mix. For now, CMS plans to leave the payment system as-is for the most part, but the agency will use 2018 as an opportunity to explore changes with stakeholders. In terms of payment amounts, CMS will enact an $80 million reduction in 2018, a cut mandated by the Affordable Care Act. The APTA fact sheet can be accessed on the association's Medicare Payment and Policies for Home Health webpage, under "APTA Fact Sheets and Summaries."

    Want even more information on CMS-related changes in store for 2018? Don't miss the December 13 Insider Intel call-in program that will include information on HH PPS and OPPS provisions. The program is available at no cost to APTA members.

    4 Things to Do Now That the 2018 Fee Schedule Is Out

    By now, most physical therapists (PTs) have heard the news: the final 2018 Medicare Physician Fee Schedule (PFS) released in early November by the US Centers for Medicare and Medicaid Services (CMS) included some significant variations from the PFS proposed in July. Instead of finalizing CPT code values that were the same as—and occasionally larger than—current values, CMS opted to offer up a more complicated combination of cuts and increases that could affect PTs in different ways, depending on their case-mix and billing patterns.

    So what should PTs do in the wake of the new PFS? Here are APTA's top 4 suggestions.

    1. Know the design process for the fee schedule.
    It's important to understand what led to the changes to provide context, a slight sense of relief, and a reminder of why payment needs to move toward value-based models and away from fee-for-service.

    The PFS now set to debut January 1, 2018, is the CMS response to an American Medical Association (AMA) committee's recommendation on potentially "misvalued" codes associated with a wide range of professions, not just physical therapy. When the process began in early 2016, many predicted that the final outcome would be deep cuts to nearly all valuations—as much as 10% or more overall. APTA and its members fought hard to substantiate the validity of the current valuations, and even the need for increases in some areas. The end result was a significant improvement from where things were headed at the start of the process.

    That's not to say it's been an entirely satisfying process from start to finish. This recent PT in Motion News story goes into more detail about the sometimes-frustrating journey from points A to B.

    2. Understand what's being changed.
    Just about everything that happens at CMS is complicated, and the process that led to the new CPT code valuations is no exception. Still, a working knowledge of how CPT codes are valued is helpful in understanding why the PFS contains such a mix of positives and negatives.

    One important thing to understand is that code valuation is actually a stew of 3 separate elements, known as relative value units (RVUs). These are estimations of the labor, expense, and possible professional liability involved in performing any given treatment or evaluation task associated with a CPT code. The 3 types of RVUs are known as "work," "practice expense" (PE), and "professional liability." The coding valuation differences between the proposed and final PFS were due to changes to the PE RVUs only.

    This wasn't part of the proposed rule. While the AMA Relative Value Scale Update Committee Health Care Professions Advisory Committee did recommend changes to PE RVUs, CMS initially opted to not adopt those suggestions. When the final rule was released 3 months later, CMS—without seeking input from APTA or any other stakeholders—did an about-face and adopted the changes to PE RVUs.

    So what? The answer is twofold: first, the tweaks to PE RVUs mean it's difficult to make many sweeping generalizations about how the new PFS will affect individual practices and clinics; second, it's worth noting that individual work RVUs either remained unchanged or increased.

    A more detailed explanation of how the codes were affected is available in an APTA fact sheet on the 2018 PFS (listed under "APTA Summaries and Fact Sheets"). For a more complete explanation of RVUs and the differences between the 3 types, check out this APTA podcast on the CPT valuation process.

    3. Get a sense of how you might be affected.
    A sense of history and understanding of detail are all well and good, but the bottom line is your bottom line.

    Here's the complication with the 2018 PFS: because of the wide variation in upward and downward adjustments, it's hard to make statements about how PTs in general will be affected. CMS estimates the overall impact at a 1%-2% reduction, but a lot depends on the types of patients a PT or clinic typically sees and what interventions are commonly used. Some providers could see increases.

    In an effort to clear up some of the uncertainty, APTA offers a calculator than can help you see how your typical case-mix would fare in the new PFS. The calculator, offered in Microsoft Excel, allows you to enter different codes to see what changes to expect, given your Medicare service area.

    4. Keep learning.
    There's much more to understand about the PFS—not just in terms of the details of how the new rule will work, but in terms of APTA's work to safeguard CPT codes throughout the misvalued codes review process.

    One great way to learn more about what to expect is coming up in December, when the association hosts a free webinar on Medicare changes for 2018 on December 6 from 1:00 pm to 2:00 pm ET. The webinar will be presented in a "flipped" format, meaning that when you register, you'll be provided with a prerecorded presentation to listen to in advance. That way, more of the actual session can be devoted to live interaction with the presenters. Be sure to sign up—and listen up—soon.

    Another opportunity is available December 13, when APTA hosts an "Insider Intel" phone-in session that will cover many of the same topics, albeit in a pared-down 30-minute session, from 2:00 pm to 2:30 pm ET. Instructions for signing up for this session are on APTA's Insider Intel webpage.

    The 2018 Physician Fee Schedule: Where We Are, How We Got Here, What's Ahead

    Here are a few things that can be said about the 2018 Medicare physician fee schedule (PFS) released by the US Centers for Medicare and Medicaid Services (CMS):

    1. It's a mixed bag in terms of adjustments to current procedural terminology (CPT) codes commonly used in physical therapy, with some values going up, and others being cut.
    2. Physical therapy isn't the only profession that saw CPT code reductions: otolaryngologists, nurse anesthetists, and urologists, to name a few, are also bracing for cuts.
    3. It could've been a lot worse—up to a 10% cut or more based on changes to the practice expense.
    4. Statements 1-3 aren't much consolation when you're a physical therapist (PT) facing estimated average payment reductions between 1.3% and 2% (but again, this is hard to pinpoint: there will be increases, but in other cases decreases will be even worse).

    What happened?
    Just a few months ago, the outlook was good for PTs when it came to next year's PFS. After a 2-year American Medical Association analysis of CPT codes that CMS believed may have been potentially "misvalued," the proposed rule that emerged was a clear win for the profession: no cuts to codes values, and even a few increases. From the perspective of the profession, the proposed rule adopted all of the positive recommendations from AMA—namely, no cuts and a few increases to work relative value units (RVUs)—and none of the damaging AMA recommendations, which included adjustments to practice expense (PE) inputs that would affect payment. Things were looking good, and APTA and its members advocated strongly for the rule as proposed.

    When the final rule was issued in November, things stopped looking so bright. Between release of the proposed rule and publication of the final version, CMS veered away from its typical process when it announced—without warning and without allowing opportunity for input from any stakeholders, including APTA—that it would reverse its decision and adopt the recommendations related to PE inputs. The rule change has altered the payment landscape for PTs in ways that are still being worked out by APTA. The association has published a summary of the rule on its website (listed under "APTA Summaries and Fact Sheets").

    Mapping the landscape
    While it's true that the final rule will result in increases in some areas, some of the payment reductions that will go into effect next year will hit home for some PTs. What is known for certain is that a few of the most commonly used codes in physical therapy will see a drop, including manual therapy, therapeutic exercise, mechanical traction therapy, and aquatic therapy.

    At the same time, other codes will increase—some significantly. Gait training therapy values will increase, as will neuromuscular reeducation, and therapeutic activities. Values for the 3-tiered evaluation codes adopted by CMS in 2016 also will rise (although the single value for all 3 tiers is maintained), in addition to orthotic management and training (first encounter), and prosthetic training (first encounter).

    APTA is putting final touches on a calculator that will help members get a more precise estimate of the potential impact of the new rule, given their particular practice circumstances. The calculator is set to be released early next week.

    "While it's clear that the CMS reversal from its proposed rule will result in drops to some of the codes used frequently by PTs, the bottom line effects of the new rule will vary depending on case mix and billing patterns," said Carmen Elliott, MS, APTA vice president of payment and practice management. "The overall 2% drop estimated by CMS doesn't take that variation into account. There will be some providers who will see reductions in payment of anywhere from 1% to 2%, but we anticipate that others could see overall increases."

    How we got here
    "This is frustrating, both in terms of the payment reductions as well as the way CMS surprised stakeholders with its reversal from the proposed rule. The cuts will be hard on some physical therapist practices," said APTA Vice President of Government Affairs Justin Elliott (no relation to Carmen Elliott). "It’s also true that the initial projections, long before the initial proposed rule, were far more bleak."

    Justin Elliott is referring to the way CMS handles codes that it believes may be "misvalued"—often read as a euphemism for "overpaid." It's a complex, multi-year process overseen by the AMA's Relative Value Scale Update Committee (known as RUC) Health Care Professions Advisory Committee (HCPAC). The RUC HCPAC engages in dialogue with stakeholder groups, including APTA, and conducts surveys of individual providers before issuing recommendations on how codes should be valued. The survey of PTs was conducted in October 2016.

    When the process began in early 2016, indications were that, overall, CPT codes commonly associated with physical therapy could see a double-digit cut. APTA staff and CPT advisors worked with the RUC HCPAC to move recommendations away from that potentially catastrophic change, and survey responses from PTs helped to reinforce the notion that current code values were not far off—at least in terms of averages across all codes.

    Given where things seemed to be headed in 2016, the release of the final rule, though far less than ideal, does amount to a win—of sorts. And context is important: physical therapy wasn't alone in professions with codes on the CMS chopping block, with otolaryngologists, anesthesiologists, nurse anesthetists, urologists, and vascular surgeons all seeing overall code reductions between 1% and 2%, according to CMS estimates.

    What's next?
    According to Justin Elliott, "APTA is exploring all avenues to advocate against these cuts before they take effect on January 1, 2018." He added, "All options are on the table and every path is being evaluated for our response to the final rule."

    Those advocacy efforts will require APTA and its members to have a solid understanding of just how the CPT changes impact them during the coming year, according to Carmen Elliott, who said that the key to getting insight on the effects is for PTs to continue to code and document appropriately while they evaluate their case mixes and other factors. "The only way to truly understand the effects of these changes is for our coding efforts to remain consistent," she said.

    At the same time, APTA President Sharon Dunn, PT, PhD, thinks there's an even bigger picture to be considered.

    "We can't yet say what the overall impact will be as a result of these code value changes, and we know that the effects will vary from provider to provider," Dunn said. "What we can say for sure is that these kinds of adjustments and recalculations truly underscore the need for health care providers to move toward value-based payment models that truly reflect the value of physical therapist services’ triple aim—improving the experience of care, improving population health, and reducing costs. The CPT code structure has 1 foot firmly planted in the outmoded fee-for-service world. That needs to change."

    Bill Allowing PTAs in TRICARE Ready for President's Signature

    Well, that was quick: a week after an agreement was reached on legislation that would allow physical therapist assistants (PTAs) to participate in the TRICARE payment system used throughout the US Department of Defense health care system, both the US Senate and House of Representatives have passed the bill. It's now ready to be signed by the president.

    The PTA provisions are part of the National Defense Authorization Act (NDAA) that includes language proposed by APTA to add PTAs and occupational therapy assistants to the TRICARE program.

    "This is a significant win for PTAs, but an even bigger win for patients in the TRICARE program," said Michael Hurlbut, APTA senior congressional affairs specialist. "The important services PTAs provide should be as accessible as possible, regardless of payer."

    Defense Bill Headed for Final Votes Will Include PTAs in TRICARE

    Physical therapist assistants (PTAs) are now closer than ever to being included as accepted providers under TRICARE, the payment system used throughout the US Department of Defense (DoD) health care system.

    Last week, the Armed Services Committees for both the US House and Senate reached an agreement on a National Defense Authorization Act (NDAA) that includes language proposed by APTA to add PTAs and occupational therapy assistants to the TRICARE program. The APTA-backed amendment was introduced by Sen Thom Tillis (R-NC) in July and was included in the Senate version of the bill that passed in September. The amendment can be found on page 379 of the NDAA.

    The legislation will next advance to the House and Senate, where it is expected to pass in both chambers.

    "This is great news for PTAs and patients in the TRICARE program," said Michael Hurlbut, APTA senior congressional affairs specialist. "We hope to see a bill ready for the president to sign sometime in December. Once signed into law, the changes will probably be issued through regulation, and we could see PTAs included in the TRICARE program as early as next year." APTA will work with the DoD as the process moves forward, he added.

    That wasn't the only piece of good news in the NDAA. Legislators also included amendments to address opioid prescribing within the DoD health care system, including instructions for the Secretary of Defense to "[Develop] methods to encourage health care providers of the [DoD] to use physical therapy or alternative methods to treat acute or chronic pain."

    Required Rehabilitation Benefits Under Threat: Time to Make PT Voices Heard

    The US Department of Health and Human Services (HHS) is pushing for changes that would allow states to dramatically alter the way essential health benefits (EHBs) are managed, opening up the possibility for consumer confusion, market disruption, and reductions in patient access to services including rehabilitation.

    APTA says it's time to push back.

    Now available on the APTA website: a template letter that makes it easy for physical therapists and physical therapist assistants to let HHS and the US Centers for Medicare and Medicaid Services (CMS) know how the EHB proposal will harm both patients and physical therapy practices. The letter allows sender to personalize contents to reflect their individual circumstances and practice settings, but ensures that the overarching message is consistent—that the proposed changes "are likely to have a detrimental impact on not only my practice, but also patients' ability to access medically necessary care."

    The HHS proposal would allow states to alter the minimum requirements for health insurance policies offered through a state's insurance exchange. Although states still would be required to only accept plans that included all 10 EHBs—rehabilitation among them—they could mix and match elements from other states when establishing the baseline for allowable plans, potentially shrinking coverage. Adding to the uncertainty, states would be permitted to reconfigure their so-called "benchmark plans" every year.

    Additionally, the proposal would lower the bar for benchmark plans overall, stipulating that they need be only slightly better than the skimpiest allowable employer-sponsored or self-insured group plan. More details are available in a PT in Motion News story on the proposal, as well as a notice from HHS.

    For more information on the effort to oppose the EHB proposal, contact APTA staff at advocacy@apta.org. Deadline for comments is November 27.

    CMS Drops Home Health Payment Plan Opposed by APTA

    After receiving significant opposition from APTA, the APTA Home Health Section, and other professional and consumer advocacy organizations, the US Centers for Medicare and Medicaid Services (CMS) has backed off on a proposed rule that would have dramatically altered the home health care payment landscape in ways that would have reduced care.

    Issued on November 1, the home health prospective payment system final rule for 2018 does not finalize the proposed Home Health Groupings Model (HHGM), a payment system that, among other changes, would have removed therapy service-use thresholds from the payment mix. The proposed HHGM prompted immediate outcry from a wide range of stakeholders, with APTA characterizing the rule as one that would create "perverse financial incentives" for reductions in care in home health.

    In a fact sheet published in conjunction with the release of the final rule, CMS states that it won't adopt the HHGM model for 2018 and instead "will take additional time to further engage with stakeholders to move towards a system that shifts the focus from volume of services to a more patient-centered model."

    APTA staff are reviewing the final rule and will share more details in the coming days, but the news that the HHGM will not be implemented in 2018 represents a win for patients and the association.

    "APTA had significant concerns that the HHGM would have a dramatic, negative effect on patient care," said Kara Gainer, APTA director of regulatory affairs. "Together with the Home Health Section and many of our members, we initiated a strong congressional and regulatory advocacy campaign to stop CMS from adopting the HHGM. It appears our efforts—along with those of many others in the home health industry—were compelling."

    Therapy Cap Breakthrough? Legislators Reach Bipartisan Agreement on Repeal

    Editor's note: An earlier version of this story indicated that the KX modifier would not be required for claims less than $3,000. This story has been updated to reflect that the modifier will be required to accompany all claims over $1,980.

     

     After 20 years of opposition from APTA and 17 years of 11th-hour congressional patches to an inherently flawed policy, the Medicare therapy cap may be on its way out for good.

    But nothing's certain yet, and there are many details still to be worked out.

    On October 26, APTA representatives attended a meeting on Capitol Hill during which lawmakers from the House Energy and Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee announced a bipartisan agreement to end the therapy cap. The road from proposal to actual repeal can be long, and success isn't guaranteed, but if the proposal survives it would represent a major victory for patients and the physical therapy profession.

    Details are still emerging, but the current proposal would eliminate the $1,980 hard cap on physical therapy and speech-language pathology services (as well as the $1,980 cap on occupational therapy) on January 1, 2018, with claims above the $1980 threshold requiring the KX modifier. At the same time, the threshold for targeted medical review would be lowered from the current $3,700 to $3,000 through 2027. While the threshold amount for medical review would be lowered, the US Centers for Medicare and Medicaid Services (CMS) would not receive any increased funding to pursue expanded medical review.

    In more potential good news for patients and the physical therapy profession, the proposal does not include prior authorization requirements, a provision that had been included in earlier repeal attempts.

    APTA staff are reviewing the proposal in detail, but according to APTA Vice President of Government Affairs Justin Elliott, the basics look promising. Repeal of the therapy cap has been a central focus of APTA's public policy efforts since the cap’s introduction in 1997.

    "This is an important step, particularly because this is a bicameral, bipartisan agreement between the House and the Senate," Elliott said. "That kind of backing provides very real momentum for the repeal effort."

    Crossing the finish line, however, is not a sure thing, and there are many details that need to be worked out, not the least of which is the need for legislators to identify "pay fors"—cuts and offsets that can be offered up to cover the increased costs that may be associated with elimination the cap, Elliott said.

    In a joint statement from the House and Senate committees involved in the agreement, leaders characterized the proposal as a "major breakthrough" that solves a serious Medicare problem.

    "Arbitrary caps on these important services have never made much sense, as it is an important medical service that can both help patients avoid surgery or, when surgery is needed, help them recover their quality of life," the leaders said. "Now we must shift our work to ensuring that this important policy is fully offset."

    APTA Expands Efforts to Address the Opioid Crisis

    The country’s response to the national opioid crisis is evolving: President Trump announced that he will soon declare opioid abuse a national emergency; cities are lining up to sue pharmaceutical companies; and state attorneys general are pressing insurance companies to better support nondrug approaches to pain treatment.

    Meanwhile, APTA has been bringing the physical therapy profession’s voice and perspective to the national dialogue on how best to reshape the health care system’s approach to pain treatment and management.

    The association has been active in responding to opioid abuse since 2015, when APTA was invited to join a White House initiative under then-President Barack Obama. In 2016, APTA launched the #ChoosePT opioid awareness campaign, a high-visibility effort that was championed by individual members and state chapters, and received both state and national recognition.

    So what’s APTA been up to since then? A lot.

    We were at the table for the first-ever Integrative Pain Care Policy Congress.
    Sponsored by the Academy of Integrative Pain Management (AIPM), this recent event brought together representatives from organizations including APTA, the American Pharmacists Society, the American Osteopathic Association, BeaconHealth, Kaiser Permanente, the National Association of Social Workers, the American Cancer Society, and Aetna for discussions and presentations on how to best address conflicting pain care guidelines.

    APTA Director of Regulatory Affairs Kara Gainer, JD, represented the association, participating in a panel discussion on how to strengthen state-level policy on integrative pain management.

    We’re helping to draft a national playbook on opioid prescribing and effective pain management.
    The association is working with 40 other organizations as the Opioid Stewardship Action Team, a group assembled by the National Quality Forum (NQF), a health care research and advocacy group. APTA is a member of NQF.

    According to NQF, the goal of the team is to work on “strategies and tactics to support appropriate opioid prescribing practices and more effective pain management, particularly for individuals with chronic pain and those at risk of dependence and addiction.” That work will result in a “playbook” in March 2018 that NQF hopes will help to establish a more cohesive approach to pain management. In addition to APTA, task force participants include representatives from the US Centers for Disease Control and Prevention (CDC), the American Nurses Association, Kaiser Permanente, the US Centers for Medicare and Medicaid Services, Magellan Health, the American Society of Health System Pharmacists, and the Substance Abuse and Mental Health Services Administration. Alice Bell, PT, DPT, an APTA senior payment specialist, is representing the association on the task force.

    We’re keeping members in the loop, adding to evidence-based resources for pain management, and planning for next steps in advocacy.
    Policy-based approaches to the opioid crisis were front-and-center at the most recent APTA State Policy and Payment Forum in September, which featured a presentation by representatives from the National Journal. APTA also is thinking about the future and is working through its Public Policy and Advocacy Committee to develop a roadmap for where the association can have the biggest impact on policy.

    At the same time, APTA continues to add resources to put physical therapists in touch with the best evidence on pain assessment, treatment, and management through PTNow. The association is engaged in activities related to reviewing and developing CPGs, including reviewing CPGs related to opioid therapy for chronic pain from external groups and supporting the Education Section and Orthopaedic Section of APTA in the development of a CPG focusing on patient education and counseling for the management of chronic pain.

    APTA members have been awarded federal research grants to study pain treatment.
    The US Departments of Defense, Health and Human Services, and Veterans Affairs have created an interagency partnership that aims to focus on research related to nondrug approaches to pain treatment for military and veteran personnel. The partnership’s first order of business: providing grant awards to fund research projects. APTA members Julie Fritz, PT, PhD, FAPTA, and Steven George, PT, PhD, each were named as recipients in the first round of grants.

    According to a press release from the partnership, Fritz will research a “stepped care” approach to the treatment of low back pain. George will conduct a planning and demonstration project to improve access to nondrug therapies for low back pain through the Department of Veteran’s Affairs health care system.

    #ChoosePT continues to gain momentum.
    The video supporting the #ChoosePT campaign is still making the rounds nationally, while, more recently, #ChoosePT ads are appearing on national news websites during October. Additionally, the campaign toolkit was updated with several new graphics and resources—including the opportunity to purchase #ChoosePT t shirts at cost.

    The campaign also has advanced through the efforts of members. Most recently, APTA collaborated with student volunteers in New York to bring the #ChoosePT message to the Today Show in September and Good Morning America in October.

    We’re reaching out to other stakeholders.
    Over the past year, APTA staff and representatives have met with representatives from the Food and Drug Administration, the Department of Veterans Affairs, the Health Resources and Services Administration, CDC, and several other agencies and groups to discuss the importance of patient access to nondrug approaches to pain. Coming up: meetings with the Indian Health Service and the Administration for Community Living.

    APTA President Sharon Dunn, PT, PhD, believes there’s good reason for the association’s multifaceted approach to the issue.

    "We need to change the culture around pain management in this country—that’s going to require raising public awareness through efforts such as the #ChoosePT campaign, but it’s also important that individuals and organizations throughout the health care space are actively engaged in working to enhance understanding of safe and effective pain management through interdisciplinary care,” Dunn said. “It’s important that APTA and the physical therapy profession participate in these efforts because we bring a unique perspective to the conversation.”